Use of abbreviations in the nursing records of a teaching hospital
DOI:
https://doi.org/10.15253/2175-6783.2016000200008Palabras clave:
Nursing Records, Abbreviations, Health Communication, Nursing, Team.Resumen
Objective: to evaluate the use of abbreviations in nursing records of a teaching hospital and describing their profile in different sectors, work shifts and professional nursing categories.Methods: documentary study that analyzed 627 nursing records in 24 patient charts using a systematic observation script. Results: we identified 1,792 abbreviations, and 35.8% were nonstandard. The incidence of abbreviations was higher in the Intensive Care Unit, used by nurses and in the night shift. Conclusion: abbreviations are part of the day-to-day of nursing records. The use of nonstandard abbreviations make difficult to understand the note content, can generate misinterpretations, put at risk the users’ safety and impair the continuity of labor work.Descargas
Publicado
2016-04-30
Cómo citar
Carneiro, S. M., Dutra, H. S., Costa, F. M. da, Mendes, S. E., & Arreguy-Sena, C. (2016). Use of abbreviations in the nursing records of a teaching hospital. Rev Rene, 17(2), 208–216. https://doi.org/10.15253/2175-6783.2016000200008
Número
Sección
Research Article